JUDY ROSENFELD, MPH



Lynne Budde Sheppard M.A., L. Ac 3710 168th St NE, Suite A101, Arlington, WA 98223 360-653-3403

Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. My ability to diagnosis and treat your condition is based on a complete health history. All of your answers are completely confidential. This information will not be released to any person except with your authorization.

Health History Questionnaire Date __________/ __________/__________

|Name |

|Address Street City/State/Zip code |

| |

|Home phone Work phone Email address |

|Date of Birth Age Occupation |

|Height Weight Family Physician Phone |

|Emergency contact Emergency contact phone Relationship |

|Referred by Have you ever been treated with acupuncture before? Would you like to receive an email newsletter? |

What is the main problem (s) you would like help with? ______________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

When did the problem begin? (Date)___________________Is it getting better or worse? _____________

Do you know what caused the problem? ____________________________________________________

______________________________________________________________________________________

Have you been given a diagnosis for this problem? If so, what is it?______________________________

______________________________________________________________________________________

What kinds of treatment have you tried? ____________________________________________________

______________________________________________________________________________________

Current/Past Medical History (Please check if you currently have, or have had in the past. Include date)

( AIDs/HIV ( Diabetes ( Multiple Sclerosis ( Thyroid Disorder

( Alcoholism ( Emphysema ( Mumps ( Tuberculosis

( Allergies ( Epilepsy ( Pacemaker ( Typhoid Fever

( Appendicitis ( Goiter ( Pleurisy ( Ulcers

( Arteriosclerosis ( Gout ( Pneumonia ( Venereal Disease

( Arthritis ( Heart Disease ( Polio ( Whooping Cough

( Asthma ( Herpes ( Rheumatic Fever ( Tonsillectomy

( Birth Trauma ( Hepatitis ( Scarlet Fever ( Other (Specify)

( Cancer ( High Blood Pressure ( Seizures _________________________

( Chicken Pox ( Measles ( Stroke _________________________

( Migraines

Surgeries (Type and date)____________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Significant Trauma (Physical or emotional—auto accidents, falls, divorce, death in family. Please include date.)

_____________________________________________________________________________________________

Do you have any scars? Where? Are they painful? _______________________________________________________________________________________________________________________________

Dental Work (Type and date)_____________________________________________________________________

Family Medical History ( Allergies ( Alcoholism ( Diabetes ( Seizures

( Arteriosclerosis ( Cancer (type) ( Heart Disease ( Stroke

( Asthma ____________ ( High Blood Pressure ( Other

( Depression _________________

Please list the medications taken in the last two months. (Include medications, vitamins, herbs, etc.)

______________________________________________________________________________________

______________________________________________________________________________________

Do you experience occupational stress? (Chemical, physical psychological)_______________________

______________________________________________________________________________________

Do you exercise? (What type and how often)________________________________________________________

Please describe your typical meal for:

Breakfast:_____________________________________ Snacks____________________________________

Lunch________________________________________ Snacks___________________________________

Dinner_______________________________________ Snacks___________________________________

Do you smoke cigarettes? (Yes/no)___________ If yes, how many per day (week)________________

Do you drink alcohol? (Yes/no)______________ If yes, how much per day (week)________________

How much coffee, tea or cola do you drink per day? ______________________________________________

Please describe any drug use:________________________________________________________________

PLEASE CHECK ANY SYMPTOMS YOU HAVE HAD IN THE LAST 3 MONTHS

|General |( Psoriasis |( Cataracts |

|( Chills |( Hives |( Eye dryness |

|( Fever |( Acne |( Excessive tears |

|( Sweat easily |( Recent moles |( Discharge from eyes |

|( Night sweats |( Hair loss |( Poor hearing |

|( Localized weakness |( Dandruff |( Ringing in ears |

|( Bleed or bruise easily |( Fungal infections’ |( Hearing aid |

|( Peculiar tastes or smells | |( Earaches |

|( Strong thirst (for hot or cold drinks) |( Other hair or skin problem:___________ |( Discharge from ears |

|( Fatigue |________________________________ |( Nose bleeds |

|( Sudden energy drop | |( Sinus problems |

|Time of day?___________________ |Head, Eyes, Ears, Nose, Throat |( Excessive phlegm |

|( Edema Where?_________________ |( Dizziness |( Grinding teeth |

|( Poor sleep |( Migraines |( Jaws Clicks |

|( Tremors |( Headaches |( Concussions |

|( Poor balance |Location:________________________ |( Recurrent sore throats |

|( Cravings |( Facial Pain |( Hoarseness |

|( Change in appetite |Location:________________________ |( Enlarged thyroid |

|( Poor appetite |( Glasses |( Swollen glands |

|( Weight gain |( Poor Vision |( Sores on lips or tongue |

|( Weight loss |( Night blindness |( Gum problems |

|Skin and Hair |( Blurry vision |( Teeth problems |

|( Rashes |( Color blindness |( Other head or EENT problems: |

|( Itching |( Blind field |_________________________________ |

|( Change in hair or skin |( Spots in front of eyes |_________________________________ |

|( Ulcerations |( Eye pain |____________________________ |

|( Eczema |( Eye strain | |

| | | |

| | | |

| | | |

|Cardiovascular |Genito-Urinary |Musculoskeletal |

|( High blood pressure |( Pain on urination |( Neck Pain |

|( Low blood pressure |( Urgency to urinate |( Shoulder pain |

|( Chest discomfort/pain |( Frequent urination |( Back pain |

|( Heart palpitations |( Blood in urine |( Elbow pain |

|( Cold hands or feet |( Decrease in flow |( Hand/wrist pain |

|( Swelling of hands |( Unable to hold urine |( Hip pain |

|( Swelling of feet |( Dribbling |( Knee pain |

|( Blood clots |( Kidney stones |( Foot/ankle pain |

|( Fainting |( Impotency |( Muscle pain |

|( Difficulty in breathing |( Change of sexual drive |( Muscle weakness |

| |( Genital itching | |

|( Other heart/vessel |( Sores on genitals |( Other______________________ |

|problems:___________________________________________|( Waking to urinate at night? |_____________________________ |

|____________________________________________________|How often?________________ |Neuropsychological |

|_________ | |( Seizures |

|___________________________ |(Other Genital/urinary system |( Areas of numbness |

|Respiratory |problems_________________________ |( Tics |

|( Cough |___________________________________________________|( Sleep disorder |

|( Asthma/wheezing |___ |( Concussion |

|( Pain with a deep breath | |( Bad temper |

|( Difficulty in breathing when |Pregnancy and Gynecology |( Irritability |

|lying down |Number of pregnancies______________ |( Depression |

|( Production of phlegm |Number of births__________________ |( Frustration |

|Color of phlegm?_________________ |Number of premature births__________ |( Sadness |

|( Coughing blood |Number of miscarriages_____________ |( Anxiety |

|( Pneumonia |Number of abortions_______________ |( Easily susceptible to stress |

|( Bronchitis |Age at first menses________________ |( Vertigo |

| |Days between menses______________ |( Loss of balance |

|( Other lung |Duration of menses (days)___________ |( Poor memory |

|problems____________________________________________|Date of first day of last menses: |( Substance abuse |

|________________________________ |__________________________ |( Abuse survivor |

|Gastrointestinal | | |

|( Vomiting |( Heavy periods |Have you been ever been treated for emotional |

|( Nausea |( Light periods |problems? |

|( Acid regurgitation |( Painful periods |( Yes ( No |

|( Bad breath |( Irregular periods | |

|( Hiccup |( Changes in body/psyche prior |Have you ever considered or |

|( Bloating |to menstruation |Attempted suicide? |

|( Diarrhea |( Clots |( Yes ( No |

|( Constipation |( Menopause | |

|( Chronic laxative use |Age_______ Year_________ |Other neurological or psychological |

|( Blood in stools |( Vaginal discharge |Problems:__________________________ |

|( Black stools |( Postcoital bleeding |___________________________ |

|( Mucous in stools |( Vaginal sores |___________________________ |

|( Abdominal pain or cramps |Date of last Pap _____________ |***Any health issues not |

|( Gas |( Breast lumps |mentioned on this form: |

|( Rectal Pain |( Nipple discharge |____________________________ |

|( Burning anus | |____________________________________________________|

|( Itchy anus |Do you practice birth control?___________ |____________________________________________________|

|( Hemorrhoids |__________________________ |____________________________________ |

|( Anal fissures | |____________________________________________________|

| |What type and how long?_______________ |________________________________ |

|( Other GI problems:________________ |________________________________ | |

|____________________________________________________|___________________________ | |

|_____________________________ |___________________________________________________| |

| |______________________________ | |

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